Allergy and asthma proceedings最新文献

Background: Although the gold standard for diagnosing beta-lactam antibiotic (BLA) allergy is the drug provocation test (DPT), there is no standardized protocol for children. Objective: We aimed to evaluate the clinical features and DPT results of children with a history of low-risk non-immediate reactions (NIR) to BLA who underwent initial direct single therapeutic dose challenge with a 5-day prolonged DPT. Methods: We retrospectively evaluated children ages 0-18 years with a history of low-risk NIRs to BLAs. On the first day of provocation, a single-dose DPT protocol without any skin test was administered at the clinic. The therapeutic dose was adjusted to not exceed the maximum single-unit dose (MSUD) for age and weight. The DPT protocol was administered with 100% of MSUD. To identify children with delayed reactions, the parents or caregivers were told to continue giving the medication at home for 5 days. Results: One hundred and nine children were included in this study. The median (interquartile range) age of the children was 62.5 months (26.5-94 months). Of the suspected drugs, the main culprit drug was amoxicillin-clavulanic acid for 89 children (81.7%). The most common clinical manifestation was maculopapular exanthema, which occurred in 85 children (78%), and 8 (7.3%) had a positive DPT result. Three children (2.8%) developed a reaction after the first DPT dose. The remaining children continued to use the suspected BLA at home. Five children (4.7%) developed a reaction while using the drug at home. All the children with positive DPT results developed mild cutaneous signs and presented with a reaction to amoxicillin-clavulanic acid. None had a systemic or severe cutaneous reaction. Conclusion: Initial direct single therapeutic dose challenge with a 5-day prolonged DPT is a useful and safe way to assess low-risk NIRs to BLAs in children.

Background: There is a greater prevalence of cognitive impairment among ethnic and/or racial minorities, and cognitive impairment is a barrier to asthma self-management (SM) behaviors and outcomes in older adults. Objective: The aim of this study was to examine the relationship between cognitive impairment, assessed by using the Montreal Cognitive Assessment (MoCA), and asthma SM behaviors and outcomes in a sample of predominantly Black and Latino participants. In addition, we evaluated whether using two different MoCA cutoff scores influenced the association between cognitive impairment and asthma outcomes. Methods: Baseline cross-sectional data were extracted from a longitudinal study of older adults with asthma (N = 165) ages ≥60 years. Cognition was assessed by using the MoCA. Asthma Control Questionnaire, asthma-related quality of life (AQOL), and inhaled corticosteroid (ICS) adherence were assessed by using self-report. ICS dosing was collected through chart review and inhaler technique was observed and rated. Results: Using established MoCA cutoff scores of 23 and 26 yielded 45% and 74% cognitive impairment rates, respectively. Cognitive impairment, defined by using the cutoff score of 23, was significantly associated with worse asthma control (p = 0.04) and worse ICS adherence (p = 0.01). With a cutoff score of 26, only AQOL was significantly associated with cognitive impairment (p = 0.03). Race and/or ethnicity moderated the relationship between cognitive impairment and asthma control with a MoCA cutoff score of 23, and between cognitive impairment and AQOL with a MoCA cutoff score of 26. Conclusion: Cognitive impairment in older adults with asthma is associated with important clinical outcomes, but this relationship is influenced by the cutoff score used to define cognitive impairment.

Background: Hereditary angioedema (HAE) is a complex disorder with a wide array of treatment options. Shared decision-making (SDM) should be used to ensure that patients are choosing their best treatment option. The goal was to develop and psychometrically test a brief instrument for assessing the patient's perspective of the SDM process during his or her clinical encounters with an HAE specialist/allergist. Method: We hypothesized that SDM could be used effectively to help patients in their choice of therapy for HAE. Ten HAE treating physicians from the United States with a total of 50 patients with HAE used SDM to help patients choose the best prophylactic therapies (oral kallikrein inhibitor, androgens, subcutaneous C1 inhibitor replacement therapy, intravenous C1 inhibitor replacement therapy, monoclonal antibody kallikrein inhibitor) for their HAE and then completed surveys to analyze the effectiveness of the implementation of SDM as a quality indicator in health services assessment. Results: The congruence of answers between the physicians and the patients was then analyzed; 90% of the patient-physician pairs agreed that the advantages and disadvantages of the treatment options were precisely explained; 92% of the patient-physician pairs agreed that the physician helped them understand all the information and that the physician asked them which treatment option they preferred; 88% of the pairs agreed that the different treatment options were thoroughly weighed and 92% of the pairs felt that they selected a treatment option together. Conclusion: In summary, SDM is being implemented by treating physicians to determine the best management options for their patients with HAE.

Background: Patients with aspirin-exacerbated respiratory disease (AERD) frequently experience symptoms consistent with eustachian tube dysfunction (ETD), which can substantially impair patient quality of life. Methods: We analyzed a cohort of 98 adult patients with AERD who participated in a longitudinal, survey-based study. Results: By assessing data over 1 year, we established that, in patients with AERD, the ear/facial subdomain of the 22-item Sino-Nasal Outcome Test (SNOT-22) questionnaire could predict performance on the 7-item Eustachian Tube Dysfunction Questionnaire, a validated instrument for the diagnosis of ETD. We then performed a re-analysis of data from a prospective, open-label study of 22 adult patients with AERD treated with dupilumab for 3 months. We found that treatment with dupilumab was associated with a significant decrease in the SNOT-22 ear/facial subdomain score, which reflects a substantial reduction in otologic symptoms and ETD within 1 month of initiating dupilumab and was sustained for 3 months afterward. Conclusion: Our findings provide evidence that dupilumab significantly improved ETD and otologic symptoms in AERD, evidenced by changes in the SNOT-22 ear/facial subdomain score. The presence of ETD and otologic symptoms should be considered when determining the optimal therapeutic course for patients with AERD.

Background: Various formulations of dog allergen extracts, including conventional dog (also known as dog epithelium) and acetone precipitated (AP) dog, have been used for skin-prick testing (SPT), with AP dog showing improved antigen content but experiencing stability issues due to precipitant formation. Ultrafiltered (UF) dog extract has been developed to address these concerns by offering comparable allergen content to AP dog. This study retrospectively compared UF dog with conventional dog and AP dog in SPT. Objective: To compare the efficacy of UF dog extract with conventional dog and AP dog extracts in detecting dog sensitization through SPT. Methods: Retrospective analysis of SPT results from a single U.S. allergy clinic was conducted. Tests performed between October 2022 and March 2024 were included. Primary and secondary outcomes were analyzed by using descriptive statistics and statistical tests. Results: UF dog, AP dog, and conventional dog showed positivity rates of 24.2%, 23.5%, and 16.3%, respectively. UF dog demonstrated significantly higher average wheal and erythema sizes compared with conventional dog and AP dog, but UF dog was not statistically different from AP dog in terms of test positivity. Conclusion: UF dog extract showed comparable number of positive tests to AP dog and a greater number of positive tests to conventional dog. Results of the study suggest UF dog as a viable alternative to AP dog, which offered improved stability and similar test responses. Further research with larger sample sizes is recommended to confirm these findings.

Background: Symptomatic dermographism (SD) is the most common form of chronic inducible urticaria. SD disease activity increases with food intake in adult patients. Whether this is also so in children with SD is currently unknown. Objective: To assess children with SD for their disease activity by standardized provocation testing before and after eating. Methods: We subjected 44 children with SD (29 girls; median [interquartile range] age 12.5 years [8.3-15 years]), before and after eating, to standardized skin provocation testing with a dermographometer. Dermographometer scores were calculated based on responses evaluated at 1-minute intervals for 10 minutes and recorded as negative (-) or positive (+ to ++++). Clinical characteristics and urticaria control test scores were documented. Results: Dermographometer scores before eating were 2.3 of 4 on average and inversely correlated with urticaria control test scores. Dermographometer scores were higher after eating than before eating. Of 44 children with SD, 35 had increased dermographometer scores after eating and 9 patients had a postprandial increase of ≥1 point. Eating-induced increases in dermographometer scores were linked to earlier whealing in 17 of 35 patients, and differences in preprandial versus postprandial dermographometer responses were more pronounced at earlier than later time points after testing. Conclusion: Disease activity, as assessed by provocation testing, is increased in most pediatric patients with SD after eating. Future studies should explore the prevalence of food-exacerbated SD in larger pediatric SD populations. Most pediatric patients with symptomatic dermographism have higher disease activity, assessed by provocation testing, after eating as compared to before eating. Standardized provocation testing and trigger threshold assessments in children with symptomatic dermographism should be performed before and after eating. Knowledge of food-exacerbated disease may help patients with the management of their symptomatic dermographism.

Shared decision-making (SDM) requires a clear-eyed view of evidence certainty, context, and equipoise in clinical care. This paradigm of care builds on the foundational ethical principle of patient autonomy, further leveraging beneficence, nonmaleficence, and justice to provide bespoke care in the appropriate clinical setting. When evidence is carefully evaluated together with acceptability and feasibility, equity, cost-effectiveness, resources, and patient preferences, an individualized assessment of the trade-off between possible benefits and harms can optimize patient management. In the setting of a conditional recommendation, it is appropriate to engage in SDM with patient partners, to the extent each patient is willing and able to engage in the SDM process. Three conversations inform SDM and include team talk, option talk, and decision talk with discussion of the plan of care. During these conversations, clear communication strategies that are specific, measurable, achievable, realistic, time sensitive, and provide assessment of absolute (not just relative) risk are important to provide necessary education to patient partners. Follow-up is key to ensure that decisions lead to effective treatment. Through this process, it is necessary to minimize cognitive overload and promote a minimally disruptive medicine approach. The acronym "HOW" promotes a holistic appraisal of evidence in context, open-minded teamwork with patients and families, and willingness to be a listening presence while serving as a partner and guide and appreciating the multidimensional and unique nature of each individual. SDM is and will continue to remain a cornerstone of appropriate medical care in settings of clinical equipoise.

In contrast to inborn errors of immunity (IEI), which are inherited disorders of the immune system that predispose to infections, malignancy, atopy, and immune dysregulation, secondary immunodeficiencies and immune dysregulation states (SID) are acquired impairments in immune cell function and/or regulation, and may be transient, reversible, or permanent. SIDs can derive from a variety of medical comorbidities, including protein-losing conditions, malnutrition, malignancy, certain genetic syndromes, prematurity, and chronic infections. Medications, including immunosuppressive and chemotherapeutic drugs, can have profound effects on immunity and biologic agents used in rheumatology, neurology, and hematology/oncology practice are increasingly common causes of SID. Iatrogenic factors, including surgical procedures (thymectomy, splenectomy) can also contribute to SID. A thorough case history, medication review, and laboratory evaluation are necessary to identify the primary driver and determine proper management of SID. Careful consideration should be given to whether a primary IEI could be contributing to autoimmunity, malignancy, and posttreatment complications (e.g., antibody deficiency). SID management consists of addressing the driving condition and/or removing the offending agent if feasible. If SID is suspected to be permanent, then antibiotic prophylaxis, additional immunization, and immunoglobulin replacement should be considered.